EnvironMentors Expense Reimbursement Form National Council for Science and the Environment Name__________________________________________ Dates of Travel_____________________________________ Address__________________________________________________________________________________________ City________________________________ State____________________ Zip_________________________________ Phone_____________________________ Email_________________________________________________________ Purpose ______________________________________ Location___________________________________________ Item
Cost
Airfare
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Ground Transportation
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Food in travel (itemized receipt)
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Other (itemize)
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TOTAL COSTS
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PREPAID COSTS
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GROUND TRAVEL RATE
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AMOUNT TO BE REIMBURSED
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Check payable to: _________________________________________________________________________________ Name
Phone
_________________________________________________________________________________________________ Address
City, State ,Zip Code
Please remit signed document and receipts (email attachment or regular mail) by Friday September 21, 2012 to: Jessica Soule National Council for Science and Environment 1101 17 St. NW #250 Washington DC 20036 202-530-2810 x224 jsoule@ncseonline.org For official use only: Project: _____________________________________ Check # ____________________________________________ Date Paid: _____________________________________Amount: ___________________________________________ Authorized by: ____________________________________________________________________________________ Tahlia Bear, EnvironMentors
Date
Authorized by: ____________________________________________________________________________________ Andi Glashow, Director of Finance, andi@ncseonline.org
Date